Coding Categories (continued) Code examples Procedure Codes Code Structure Each character in the procedure code has a specific meaning (example of medical-surgical code structure) Character 1 - Section Character 2 - Body System Character 3 - Root Operation Character 4 - Body Part Character 5 - Approach Character 6 - Device Character 7 - Qualifier Code Example - 0X6K0Z8 - Fifth ray carpometacarpal joint amputation, left hand
ICD-10-PCS 1234567 SectionBody System Root OperationBody PartApproachDeviceQualifier ICD-10-PCS S TRUCTURE
RLM.MD 01/09 ICD-10-PCS5 System Structure 16 Sections Medical and Surgical Obstetrics Placement Administration Measurement and Monitoring Extracorporeal Assistance and Performance Extracorporeal Therapies Osteopathic Other Procedures Chiropractic Imaging Nuclear Medicine Radiation Oncology Physical Rehabilitation and Diagnostic Audiology Mental Health Substance Abuse Treatment
First Character Value-Section This character refers to section of which there are 16 0 value is the medical surgical section 1 value is ob 2 placement 3 administration Etc….. 0 for med surg is the largest section (this is your first character)
Second Character Value-body system The second character defines the body system, general physiologic system or anatomic region. Some are numerical and some are alphabetic (31 body systems in the med surg section) examples: 0 central nervous system 1 peripheral nervous system 2 heart and great vessels 3 Upper arteries H skin and breast including skin and breas glands and ducts Etc…..
Third Character Value-Root Operation The third character value is the Root operation 31 root operations Examples: 1 Bypass 7 Drainage B Excision T Resection Example: Excision(B) is referring to cutting out or off a portion of the body without replacement whereas Resection(T) is referring to cutting out or off all of a body part.
Fourth Character-body part The fourth value is the body part or specific anatomical site where the procedure was performed. There are 34 body part values in each body system of these values You will locate the table to assign the rest of the code # THIS IS JUST A PIECE OF THE TABLE H: Skin and Breast Operation(3 rd character) Body Part(4 th character) Approach(5 th character) Device(6 th character) Qualifier(7 th character) 0 alteration0 scalp0 open0 drainage device 3 full thickness 2 changeB skin,Rt up arm 3 percutaneousN tissue expander 4 partial thickness B excisionC skin lt up arm 7 via natural/artif opening Y other device X diagnostic T resectionD skin rt lower arm X ExternalX no deviceZ no qualifier
Lets code… For example: (using what you have learned thusfar) Excision of malignant melanoma from the skin of the left upper arm Thus far what would our code #s be? ____ _____ _____ _____
Fifth character-Approach or technique The fifth character value is the approach or technique used to reach the procedure site. 7 approaches (these have definitions not fully explained here) 0 open (cutting through layers and other body parts) 3 percutaneous 4 percutaneous endoscopic 7 via natural or artificial opening 8 using endoscope F percutaneous endoscope X External (performed directly on the skin or mucousmembranes)
Sixth character-Device The sixth character is your device character Using your abbreviated table, what is our device code?
Seventh character-qualifier The seventh character is your qualifier. These qualifiers provide additional information about a specific attribute of the procedure What is our qualifier character for our example?
Your newly built code 0HBCXZZ 0 for medical surgery H for skin B for excision C left upper arm X External Z no device Z no qualifier